This crucial aspect, regularly missed by traditional policy and planning approaches, is becoming the norm in an increasingly globalised world, particularly in small countries with open borders [ 44 ].
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Lower-level training has been intermittently supported by UN agencies and the World Bank, as well as by a short-lived attempt in the s by the Dutch cooperation to train Community Health Workers [ 39 ]. Because of the comparatively limited interest and involvement of bilateral international agencies with successive governments, non-government organisations have traditionally played a substantial role in health service delivery in Guinea-Bissau.
Faith-based organisations—particularly those linked to the Catholic Church—were among the few to remain in the country during the war years; they are still considered one of the few providers of quality services in the country, particularly those in the capital city area.
NGOs—particularly Portugal-based ones—have since thrived, ready to occupy the space and funding previously channelled to activities carried out by the national government; the large EU-funded Integrated Mother and Child Health Programme is largely managed though NGOs contracts. For Guinea-Bissau, aid dependency translates into accepting donor agendas, with their proliferating priorities, changing fashions and de-contextualised decision-making. Some of these agendas have heavily shaped domestic developments and not always in the way expected by aid agencies. The Bamako Initiative is illustrative of such pattern; its impact on the health workforce, and in turn on access to health care and on its quality, cannot be ignored.
Together, the forces described in the previous section have commoditised healthcare provision, as witnessed in healthcare arenas as diverse as Cambodia [ 45 ], Lebanon [ 46 ] and Somalia [ 47 ].
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It is an open secret in Guinea-Bissau that fees are charged for any kind of health care. Statutory fees—and respective exemptions—are defined for specific services and drugs, with the stated objective of recovering drug costs and providing health facilities with a management fund; but in practice, such fees have been hijacked by health professionals, with charges reported to be erratic, arbitrary and at times unreasonable.
While this ubiquity of illegal charges was recognised for the comparatively prosperous capital city area [ 31 ], our interviews revealed the practice to be thriving also in the poorest rural areas. Unaffordable charges were identified as the true reason behind low service utilisation in the poorest rural regions. This system of informal charges was touted to be so institutionalised among health professionals and users alike, to be taken for granted as the official way of supplementing meagre and irregular salaries in poor regions and to make a decent living in the more expensive capital city.
The health workers interviewed declared seeing the issue of charges as intimately related to their low and erratic remuneration. As a result, many stated having to turn into managers to use these unofficial resources to run public services, purchasing drugs, hiring local support staff and paying for transport and maintenance.
Predictably, informants did not mention the portion of fees they pocket.
Guinea-Bissau, September Monthly Forecast : Security Council Report
Then you pay for petrol and small maintenance repairs. But as this month the money is tight, I have already told them they will have to wait for next month to be paid. As no effective inspection system is in place, the nature and extent of charges and mark-ups were reported to depend exclusively on the goodwill and creativity of the most senior officials in charge, on their ability to enforce those charges, and on the market to take the price. Although complaining about meagre public earnings, as well as the distance from the capital city, health workers seemed to have adjusted to the current living conditions, allocating time to other daily chores and alternative profit-generating activities.
Then I go to work. Commercialisation pervades the healthcare arena beyond the fees charged for the services provided. Professional training has been turned into a business, offering another manifestation of the same process, as described in the next section.
The public health sector currently officially employs workers in Guinea-Bissau, of which physicians and nurses. In relation to the served population, there were 1. Although on balance, the health workforce has been relatively stable during the last two decades, progress has been registered in terms of the upgrade of auxiliary health personnel, and of the reduction of support staff in favour of training general nurses and physicians [ 41 , 49 ].
While the overall number of physicians has grown by Interestingly, despite the lack of resources and low service utilisation, additional support staff is often recruited locally, including non-health personnel, retired technical staff or recently qualified health workers waiting to be appointed. These health workers tend to escape reporting, both in relation to their presence and remuneration.
When I retired, I offered to continue supporting the health centre with my expertise. But with the new [bank-based] payment system I stopped receiving my salary, and I receive payments irregularly, depending on the tasks I carry out. The nurse to physician ratio was 3. The ratio of combined nurse, auxiliary nurse and midwife to physician was 4. The officially recorded Health Workforce in Guinea Bissau, by category and regional deployment Arbitrary deployment was widely reported to be a key issue; although attempts have been made to establish a Deployment and Transfer Commission defining rules and standards to allocate new personnel to health regions according to needs, distributing health workers remains a largely opaque process, subject to political pressures and trading practices.
Health official Staff deployment driven by the motivations of health workers rather than health service needs is a widespread phenomenon [ 50 ], only more visible in an undergoverned healthcare arena. Compounding the frailty of management structures, the inadequate enticements offered to staff reluctant to accept hardship posts cannot redress the strong forces at play.
Moreover, health authorities short on relevant information could not conceivably decide about actual service needs. Health personnel training increased dramatically between and , with the reformed ENS graduating health cadres [ 51 ], against the few hundreds projected by the PNDRH, and the local Faculty of Medicine graduating in excess of general physicians with the support of the Cuban Brigade. For every nursing course we have openings, but at times we receive over applications! Physicians are both trained abroad and locally, through the Cuba-supported local Faculty of Medicine; more recently, two private medical schools started operating in Bissau, although programmes and facilities are still to receive accreditation from the MoPH, and one of the schools was shut down for irregularities in The majority of the interviewees identified quality of training as a pressing concern.
The old ones that should teach them have already gained too many bad habits, and are plainly not interested in passing on their expertise. Local church and NGO representatives working with clinical personnel claimed to have needed to retrain the health workers assigned by the MoPH before employing them in their own facilities, for lack of the required skills. No Ministry of Health MoH in-service training programme exists for updating and developing the skills of the national personnel, with the initiative left to NGOs and international agencies, launching specific training programmes as they see fit.
At the MoH level, supervision is the responsibility of the underfunded Central Inspectorate Unit, consisting of one senior official and two support staff.
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Regional Health Directorates are also charged with conducting inspection visits to their health facilities, but no specific budget lines are made available for this purpose. Privatisation from within, commoditisation of health care, privately-sustained production of health workers, are some of the recognisable characteristics Guinea-Bissau shares with other countries displaying underfunded health systems in severe disarray [ 29 ].
Such developments occurred against an official backdrop of public health provision, with health professionals eager to enter the civil service, and health authorities keen to offer jobs and other related perks. However, the persistent scarcity of domestic funding and fluctuating external assistance have exposed such patterns in clear contours in Guinea-Bissau, setting it aside from other countries such as Angola, where oil revenues have allowed an unchecked expansion of the civil service, and Mozambique, whose health sector has been propelled by generous aid flows [ 33 ].
Rather than the exception, political instability has come to represent the norm for Guinea-Bissau: future attempts to revitalise the health sector will have to factor in this permanent turmoil, as the country has not really known any other form of operating since independence. An extreme case of ungoverned health workforce is possibly what we witnessed in Guinea-Bissau.
Left to their own devices, abandoned by their official employer , with little or no supervision, health workers have gradually become the real owners and operators of health services, run to their advantage and regardless of their worth to the users. Arguably, the Bamako Initiative has been appropriated as a convenient fig leaf behind which the commoditisation of healthcare provision has progressed, rather than providing a lifeline for cash-strapped health systems, as reportedly happened in other West-African countries [ 52 , 53 ].
That health workers come to own an undergoverned health system has been recognised also elsewhere [ 54 ], although such crucial aspect is being inadequately considered in the policy and planning discourse. Health workers accept low and irregular salaries because these are probably the closest thing to a steady source of revenue. A public appointment is made more attractive by the freedom they enjoy to embark on an array of other profit-generating activities connected with their position.
As witnessed in other distressed contexts, such as the DR Congo [ 5 ], the health training system has grown spontaneously, fuelled by its own earning imperatives and market demand. As suggested for the DR Congo case, technical measures are unlikely to address the discussed shortcomings, nor will the health officials presiding over and benefitting from them, be the committed enforcers of risky and controversial structural reforms [ 13 ]. The inevitable attraction of richer urban areas, rather than the absolute lack of health professionals, is the likely cause of HRH shortages in the poorer parts of the country.
And such earning perspective motivates young people to acquire a healthcare qualification. The PNDRH provided an argument for the expansion, rather than for the regulation of the workforce [ 55 ]; but expanding a derelict health workforce without addressing its current faults is likely to make them more severe and irremediable. Can anything be done to stop the deterioration of the health workforce in undergoverned countries like Guinea-Bissau?
The scarcity of reliable information is striking, and the fluidity of the situation compounds matters, curtailing the shelf life of the available data; the MoPH and the state administration at large lacks the analytical, financing, legal and managements levers needed to intervene successfully in a field that has evolved spontaneously and now responds to market signals more than to administrative instructions.
To offset such shortcomings, external assistance should be strategic and sustained overtime, which is seldom the case for fragile states [ 32 ]. What realistic steps should be taken to develop the health workforce in Guinea-Bissau, or at least to contain its deterioration? The recognition of the current picture is sorely needed—by national and international policy-makers alike; the image of a well-meaning, understaffed and underfunded public health system struggling to bring health services to the population needs debunking.
A rational approach to identify solutions in undergoverned states should start with the macroassessment over time of the resource envelope, which would usher in a discussion among stakeholders about what sort of health system could be envisioned [ 58 ], and in turn what kind of health workforce is needed.
Present and future funding levels are likely to be meagre, which weighs against the maintenance of a conventional, large public health service delivery structure. Investing available public resources in stewardship and regulation, while leaving service delivery to private providers, is conceptually appealing, but fraught with difficulties, as demonstrated by state administrations much stronger than the one under scrutiny.
Using carrots where no sticks are available. Subsidies might motivate key actors to change behaviour; unenforceable regulatory provisions will not, and may make matters worse. But effective incentives need an intimate knowledge of the market and prompt reactions to changing conditions. External financial assistance, already the source of the largest share of public resources, can in principle steer the healthcare arena in desirable directions, once the extent of privatisation and commoditisation is recognised and provided its inputs are used coherently in a long-term, firmly contextualised and strategic way.
Aid could be used to motivate training institutions to raise quality standards against a reduction of enrolment numbers. Affordability and workloads rather than international ratios obviously beyond reach for a country as poor as Guinea-Bissau should indicate the number of health workers to be trained. Hardship and productivity rewards would offset the progressive numerical slimming of the workforce.
But better skills could not translate into better practice if the interplay of incentives remains negative, that is, if healthcare practice is conditioned by earning pressures. In principle, fewer pairs of competent hands could be paid better. Competitive salary levels could be introduced after severing health workers from the civil service. Turning healthcare structures into autonomous bodies would facilitate such a process.
Meanwhile, the registration of active health workers should be promoted, through tests awarding qualifications perceived as advantageous in the labour market, for instance by being preferred for recruitment by NGOs and charities. The resulting information would then be used for designing in-service and upgrading training programmes aimed at raising professional standards. Any HRH development plan should recognise the internationalisation of the health labour market and in turn the limits of domestic decision-making.
Guinea-Bissau offers a telling example of how a national health workforce can deteriorate under protracted stress. Analysing health systems in undergoverned states is particularly testing, given the informalisation of key aspects of healthcare provision and the subsequent unreliability of official data. The present study aimed at analysing the HRH situation in Guinea-Bissau in light of the recent literature on distressed health systems, with the objective of contributing to identifying the forces at play, the resulting distortions and the counter-measures that might be considered.
Through document analysis, focus group, semi-structured and in-depth interviews, we aimed at assessing how HRH react to protracted under-resourcing and mismanagement in the Guinea-Bissau settings. Since independence, political turbulence has impacted on the evolution of the national health workforce, from the waves of diaspora following armed conflict and coup attempts, to subsequent mutually inconsistent rehabilitation programmes sponsored by aid agencies and their inevitable repercussions on the health market Fig.
The commercialisation of public health services and flawed training and deploying mechanisms naturally ensued. Analysing in some detail the functioning of this de-regulated market will offer indications to set up incentives enticing health workers to perform better. Supervision and in-service training will identify the most serious skill gaps to be addressed in order to deliver better care.
Stronger and timely information will enable quick adjustments. Investments in local management capacity might be needed to offset the paralysis of central health authorities and of the central state administration , which might be beyond repair. GR is indebted to Alvaro Alonso Garbayo for comments and suggestions to the study methodology. The paper benefitted from friendly comments and revisions by Mark Beesley and Markus Michael.
The study is based on the findings from a study supported by an unrestricted research grand by The Calouste Gulbenkian Foundation, Portugal.